Transitioning to Person-Centered Care: a Qualitative Study of Provider Perspectives

Despite its widespread popularity and integration into health policy,^1–5 a consistent understanding of person-centered care (PCC) remains elusive. PCC stands in contrast to disease-focused care which has dominated medical practice for centuries. It is a care that prioritizes the needs, preferences, and life goals of the individuals and families receiving health services.^{2, 3} The growth of PCC has been driven by the belief that person-centered approaches can improve patient engagement and outcomes, address health disparities, and enhance the cost-effectiveness of care.⁶ Studies have shown that person-centered approaches can improve an individual’s self-management and treatment engagement, as well as their overall satisfaction with care.^7–10 However, studies that have found mixed clinical impacts of PCC attribute these findings, at least in part, to the lack of conceptual and operational clarity of person-centeredness⁸ and to the barriers to adoption perceived by providers. When it comes to PCC, many providers feel that they are either “already doing it” or that service users are “too symptomatic” to benefit from it.^{11, 12} Subsequently, providers may be less receptive to training in PCC.

The purpose of this qualitative study is to deepen our understanding of how providers understand PCC and experience the shift from the traditional medical model to person-centered care based on focus groups with community mental health providers who have participated in a person-centered care training. This study is part of a growing evidence base on how providers conceptualize and use PCC in practice.^14–17 Using thematic analysis, we aim to answer two primary questions: (1) How do providers understand person-centered care within the context of PCC training? (2) How do they experience the transition from a traditional, medical model of care to a person-centered one?

Methods

This qualitative study is part of a larger NIMH-funded hybrid randomized controlled trial (RCT) of Person-Centered Care Planning (PCCP) in fourteen community mental health clinics (CMHC) sites across two states. Person-centered care planning is an emerging evidence-based practice that targets the treatment planning process as a critical mechanism for facilitating collaborative, person-centered behavioral health services.^{18, 19}

Seven of the fourteen participating CMHC sites were randomized to the PCCP condition as part of the parent RCT. Sites in the PCCP condition received a 1-year training and technical support intervention. The training consisted of a 2-day in-person seminar for clinical supervisors and selected direct care staff that included didactic and behavioral rehearsal sessions. The training participants were then instructed to train and supervise their clinical teams in PCCP delivery. Trainees received PCCP reference manual and supplemental resources throughout the year. Over a 12-month period, teams participated in bi-weekly technical assistance (TA) calls that were facilitated by the external PCCP consultants who delivered the training over a 12-month period. TA calls provided opportunities for supervisors and direct care staff to discuss implementation issues and receive expert feedback on their service plans.

Sample

The study sample included 104 focus group participants. Two focus groups were conducted at each experimental site, one for supervisors and one for direct care staff, all of whom were part of teams that had received training in person-centered care. Approximately three to twelve providers participated in each of the focus groups. The majority of providers identified as female (N=82, 78.8%) and white (N=59, 56.7%). The average age of providers was 44.37 (SD = 11.43). Forty providers (38.5%) had a bachelor’s degree and 56 (53.8%) had a master’s degree. Providers reported time working at the agency ranging from less than 1 year to 28 years (M = 7.59, SD = 6.45). Sample characteristics are presented in Table 1.

Table 1.

Participant Characteristics

	Case managers		Supervisors
	(N = 64)		(N = 40)
	N	%	N	%
Gender
Male	12	18.75	9	22.5
Female	52	81.25	30	75
N/A			1
Race/ethnicity
White	38	59.38	21	52.5
Black	24	37.5	16	40
Native American	0	0	0	0
Native Haw/ Pacific Isl.	0	0	0	0
Asian	1	1.56	1	2.5
Multi	0	0	1	2.5
Other	0	0	1	2.5
N/A	1
Education
High school Degree	7	10.93	1	2.5
Undergraduate Degree	27	42.19	13	32.5
Graduate Degree	30	46.88	26	65
	Mean (SD)	Range	Mean (SD)	Range
Age	43.44 (12.02)	23–68	45.92 (10.39)	29–66
N = 100, N/A= 4

Data Collection

Twelve months after PCCP was introduced, focus groups were conducted at each of the sites assigned to the experimental condition to explore implementation of PCCP. A total of 15 provider focus groups (eight direct care focus groups and seven supervisor focus groups) were conducted. Topical domains addressed during the focus groups included experiences with PCCP, training staff, leadership involvement, and perspectives on person-centered care. Each of the focus groups were conducted by two master-level interviewers with experience working in CMHCs and lasted approximately 60 min. The study was approved by the New York University’s Committee on Activities Involving Human Subjects, the University’s Institutional Review Board (IRB Registration No. 00000310) and participants provided written informed consent. Participants received $20 compensation for their time. A selection of focus group questions is presented below:

• What does it mean to you to do person centered care planning?

• To what extent is PCCP being used in practice?

• How confident are you in your ability to implement PCCP?

• In what ways is PCCP beneficial to service delivery? In what ways does PCCP make service delivery more challenging?

Data Analysis

The fifteen focus groups were transcribed verbatim and entered into the Atlas-TI software for analysis. The present study used thematic analysis to interpret the data inductively and through an iterative process involving three independent researchers.^{21, 22} In thematic analysis, participants’ own words serve as the foundation for all coding decisions related to a specific research question. The first step of the analysis involved two of the researchers working together to generate categorical codes for similar ideas and patterns in the data related to providers’ perceptions and understanding of person-centered care. This first step produced an initial codebook which the researchers then used to independently code the first six transcripts. They then met to further refine and review the codebook, developing sub-categories and higher level themes. Themes emerged directly through the voices of the participants as well as from sensitizing concepts from the literature on person-centered care.^{5, 13, 23–26} The remaining nine focus group transcripts were then coded with a third researcher assisting in the final phase to resolve any inconsistencies in coding through a process of “consensus coding” to ensure researcher agreement and enhance rigor.²⁷ To ensure trustworthiness, the researchers engaged in frequent team debriefings, memoing, and the use of an audit trail.²⁷ For the present study, only themes related to the primary research question (how do providers understand person-centered care and experience the transition from a medical model of care?) were explored.

Results

Thematic analysis revealed that providers understood PCC as an individualized approach to care that emphasizes individual autonomy, freedom, and strengths. Their experience delivering PCC was often described in contrast to the traditional medical model. Therefore, their understanding of PCC and their experience of the transition to person-centered care could be described in terms of dialectical tensions. Four dynamic tensions emerged from a single primary tension of transitioning from a traditional medical model of care to a person-centered one. While some providers experienced these tensions as barriers to person-centeredness which frustrated their efforts to deliver individualized care, providers also described using their clinical skills, judgment, and the strength of the patient-client relationship to negotiate these tensions effectively. Figure 1 presents a dialectical wheel describing the four tensions between traditional and person-centered care: autonomy vs. compliance, strengths vs. symptoms, freedom vs. structure, and individualized vs. one size fits all.

Figure 1.

The dynamic tensions model was generated from the thematic analysis of focus group data from participants in the experimental arm of a person-centered care planning RCT. The model is a visual representation of the tensions mental health providers may experience when they transition from traditional care to a more person-centered approach

Autonomy vs. compliance

Providers described how person-centeredness demands respect for the rights and autonomy of service recipients and that this felt like a change from the traditional approach to care that focused more on compliance with treatment. One provider described the challenge of letting go of the compliance mindset and partnering with service users to make it work as a team:

They have the right to do a little more and we have to adapt to the changes. It’s like more doors are open for them… Because, um, I mean, they had the right to have, you know, freedom to go and do as they please, but for some, you cannot—because those rights are just abused and—but you have to learn how to work with them and make it work as a team. To me, that’s what I got from it, things are changing (Direct care provider, Site 13).

Another provider described how they understand their role in helping individuals to reach their person-centered goals. Although the participant identifies the goal, the provider can assist by coming up with objectives and interventions:

It’s all about the client—we are providing care to the clients. Clients should try to identify a goal to work on and we are trying to come up with appropriate objectives and interventions to help him or her achieve this goal, but it’s their plan, you know? So, we are not telling them that they need to work on A, B, C, or D, but…what would they like to work on (Direct care provider, Site 6).

Providers also described how person-centered care that supports service user autonomy allowed for more progress and produced more concrete results than treatment that focused on compliance. They describe how person-centered treatment goals are more attainable and changing the power dynamic seemed to waste less time:

…you are going in working on what you need to work on versus you going in with what you want to work on. I do not want to say time is wasted, but you are actually working towards something that could be attainable and changed and fixed versus I’m going in with my ideas and fighting yourself. You’re beating a dead horse in the head ‘cause you are just spinning around doing the same thing for nothing (Direct care provider, Site 6).

F4: meeting them where they are at kind of puts them in control if they are able to say what they want to work on versus us creating goals for them and saying, “all right, well, we’re going to work on this,”—when they may not necessarily want to work on that.

F5: Well, I think it helps them become more invested in achieving their goals if they are in charge of creating them and coming up with what’s important to them (Direct care provider, Site 6).

Providers from every focus group readily associated individual autonomy, service user direction, and self-determination with person-centered care. In our analyses, the autonomy principle quickly reached conceptual saturation. Providers seemed comfortable articulating this aspect of PCC, describing it as a more natural way of interacting with services users. It was also the aspect they were most likely to feel that they were already doing.

Freedom vs. structure

Providers associated person-centeredness with the freedom to set personal goals that might seem unrealistic to others. They described how they navigated the tension between supporting individuals in setting ambitious but realistic goals by providing structure. Providers described the techniques they used to help individuals to break large life goals into more manageable steps:

So if somebody says they are striving to be a astronaut, you are not supposed to change that, like if that’s their goal. So you have to really think of ways, like…what does it take to be an astronaut?...So I think sometimes it causes you to think outside the box without trying to change what they want their goal to be - because it’s their goal and not ours (Direct care provider, Site 13).

…oh, you can be an astronaut, but first before you can become an astronaut, there are some things you have to do to become an astronaut. We’re not discouraging them from achieving their goal, we are actually encouraging them, but there are steps to get to that goal (Direct care provider, Site 13).

One supervisor described how they worked with individuals who did not seem to have any goals, who would be delighted to be in bed all day:

…that tension is always there, because we know there’s just a few of our residents, who live in this house who would be delighted to be in bed all day. So, that’s what they want to do, and some of our less-seasoned direct-care staff would be, like, “well, that was their choice, that’s what they wanted to do.” But our response always is—it’s a balance between their choice and our role to help teach them skills of community living, to show them what’s out there and say, “how about if we try this today?” It’s not about forcing something, but it’s about just saying where you are right now, looking at that, and starting a process of suggesting what could be, that is still in line with your wishes as a person (Supervisor, Site 9).

The providers noted difficulties in navigating the tension between freedom and structure. At times, service users’ goals seemed impossible, unsafe, or simply unfeasible. Providers described how they were developing the clinical skills to engage service users in setting attainable and meaningful personal goals. Providers varied in their level of comfort and skill using shared decision-making and collaborative treatment planning to structure the clinical process. One supervisor described teaching staff techniques they can use to spark motivation and a greater sense of possibility when service users engage in unhealthy or counterproductive behaviors. The supervisor was teaching less seasoned providers to use the clinical relationship to deepen their understanding of service users’ explicit and implicit wishes.

Strengths vs. symptoms

Providers spoke about person-centeredness as a strength-based approach to care and experienced it as a shift from the medical model’s more symptom-focused approach. They described how clients responded positively to using treatment to set meaningful life goals, rather than just focusing on symptom reduction:

I think it is more positive in the way that people can state their own goal and it does not have to be this thing that talks about their symptoms. And you know, it’s “What do you want out of life?” more than, “What do you want to do here?” So I think the clients like that more (Direct care provider, Site 3).

A provider described how a person-centered approach did not deny the existence of mental health problems but decentered them in favor of more positive life goals:

I mean, people have mental disorders, um, mental illness to deal with, but it allows people to almost look past that to say, “I have a goal. How do I reach it in lieu of having this?” You know, even—not in lieu. “Even though I have something, how do I still reach it?” and they can still see a plan in place. They can see a light at the end of the tunnel. It’s a lot different than saying, “we’re going to work on your anger.” As opposed to that [say], “You want to get a job? Let’s work on how we can fix that so you can get this.” So it’s almost like an automatic positive reinforcement. You know, “If we work on this, then you get to this.” So they can see a road that they can go down. (Direct care provider, Site 3).

One provider described how this shift required an entire transformation in how they talk about and think about their clients’ hopes, dreams, and abilities:

…focusing more on their strengths, sort of looking beyond their mental illness and changing the way that we work with clients, how we think about them, how we talk about them. The whole idea was to help clients realize that their hopes and dreams could be actualized, that they were not just looked at as somebody with a mental illness who probably was gonna stay that way for life, in terms of their ability to function and do things (but we support them in managing their illness). But not so much looking at, “What do you really want for yourself in terms of your life? How do you want your life to be?” Living with this illness but/and, having hope. Helping them to see that there’s hope. That they can do a lot of the same things (or all of them, really) that the rest of us do, um, living with a mental illness. (Direct care provider, Site 6).

Providers described how using a strength-based approach engendered hope and purpose that can be used to fuel meaningful life changes. They pointed out how focusing on strengths-based goal setting created incentive for change, diminished resistance, and paradoxically created opportunities to address mental health symptoms.

Individualized vs. one size fits all

Providers believed person-centered care should be highly individualized and unique to every participant. They described the challenge of customizing care to individual needs when the larger health system still seemed designed to deliver one-size-fits-all treatment:

It [PCC] individualizes the treatment. However, it individualizes the treatment in a system that’s designed to treat everybody the same…Which is like conflicted. (Direct care provider, Site 8).

I personally believe that the higher up you go, the greener and greener it gets. And when it becomes really green, people do not matter. I mean, that’s just fact. That’s just a fact. But as far as what I do, you know, I do not even bother really paying attention to what the clinician says or what anybody says. When I first meet a client…I just concentrate on what they want, basically. (Direct care provider, Site 2).

One provider described having to choose between attending to an individual’s emotional needs and getting things done in treatment:

I’ve known this client for a year. If they are having that bad of a day, I’m not going to say, “Well, too bad, you got to get this done.” But then we get that pushback of, “Well, you know, you need to get this done.” But - I was being person-centered that day with how I did that. (Direct care provider, Site 2).

Providers identified barriers to delivering person-centered care at the organizational level. They described not be getting support or resources to truly individualize care and feeling pressured to shape treatment according to the needs of the agency, rather than the needs of the service user.

Discussion

The study identified four main themes that characterize direct providers’ understanding of person-centered care and their experiences transitioning to this approach to care delivery. Providers’ grasp of PCC principles and their experiences delivering care were described in dialectical terms, as they highlighted the tensions they navigated each day in practice. The dialectical model emerged from the analytic process in which it was noted that quotes related to PCC understanding or experience usually depicted tensions between PCC and traditional principles of care. Providers described the traditional model of care as being “one size fits all” and focused more on compliance, structure, and symptoms of illness. PCC on the other hand provides more individualized care that emphasizes autonomy, freedom, and strengths of the person. Depending on the clinical situation, providers described themselves as occupying different places along the continuum between the two models of care. At times, they were stymied in providing person-centered care by their own beliefs about service users’ abilities and deficiencies, echoing a common concern about person-centered care among behavioral health providers.¹² Other times, their efforts were frustrated by working within a larger health care system and environment that did not provide the resources or support needed for person-centered care. However, despite perceived challenges at both the individual and the systemic level, providers were strongly positive about this approach to care. They described the practice as not only more rewarding as they were not put in the place ofan enforcer but also ultimately more effective at supporting meaningful change in the lives of service users.

The providers’ perspectives aligned well with conceptual models that focus on PCC within the clinical dyad.^{23, 24} This confirms the intuitive appeal of person-centered care for most providers, and that difficulties they described in meeting these ideals both reside at the clinical and organizational levels of care. One novel finding from this study relates to the provider perception that PCC was more effective than the traditional approach. They described how supporting service user’s autonomy and strengths made actually created unexpected opportunities to address mental health symptoms. This finding contributes to the ongoing conversation on the complex relationship between self-determination and adherence in mental health services, which increasingly shows that when people have more say in the direction of their care, they are more engaged, and therefore, more likely to adhere to treatment and medication recommendations.²⁸ Providers may be able to activate this synergistic relationship through the use of clinical PCC techniques like shared decision making and person-centered care planning.²⁹ Mental health recovery advocates point to strategies that can be utilized to maximize choice whatever the circumstances. Often, providers must first address what has been termed “learned helplessness” resulting from years of being served in systems that have placed them in a passive role.^30–32 Enhancing concrete skills in how to practice person-centered care can also help providers maintain their focus on personal life goals while also meeting the criteria of “medical necessity.”^{19, 20]}

Given the overall endorsement of person-centered care by providers, the key to its successful implementation lies both in giving providers the concrete clinical skills to practice PCC and in better aligning organizational factors to promote PCC principles. Providers described a “one-size-fits-all” system that is heavily focused on reimbursement and the need to establish “medical necessity”, which can lead to problem focused and uniform treatment which providers experienced as antithetical to PCC principles. Past studies have explored in detail the numerous clinical and organizational barriers to PCC providers perceive.³³ These findings highlight an important aspect of this experience—that providers are actively grappling with these barriers and trying to make sense of their role in implementing a new and different approach to care. To help providers navigate this transition, PCC implementation strategies could include increasing the time providers have with service users to facilitate the type of relationship building required to fully engage people and solicit their personal life goals and using clinical supervision to guide providers in making sense of these challenges.^{34, 35} It is also necessary to ensure that organizational procedures particularly documentation and electronic health records are structured in a way to individualize care plans and communicate the uniqueness of each person across providers.

The study was limited in terms of the sample, which was composed of mental health service providers, and therefore, their perspective may be different from other health specialties that are adopting person-centered practices. The study also did not include the service user perspectives. Although focus groups were divided by direct care and supervisors, they still may have been subjected to social desirability in their views of person-centered care. As part of a larger study, the respondents were all trained in person-centered care planning, an intervention that operationalized person-centered principles in mental health service planning, so their perspectives of PCC were likely influenced by that training. Since the perceptual transition to PCC is difficult to capture, and many providers believe they are already doing it,¹¹ more research is needed that compares provider perceptions across settings at different stages of PCC implementation.

Implications for Behavioral Health

Findings suggest that the essence of person-centered care lies in the consumer-provider relationship and that resolving tensions in those relationships whether through clinical training or organizational changes is the key to implementing person-centered care. Epstein² argues that while infrastructure changes may be necessary for person-centered care, they are not sufficient for person-centered care which centers on relationships, communication, and involving the service user meaningfully in their care. Therefore, future research integrating both the provider and consumer perspectives is needed to continue moving person-centered care beyond an overall approach to a specific set of measurable and concrete behaviors.